Teleradiology. Part I. History and clinical applications

Digital otoscopy in remote consultations

Introduction

Otoscopes and otomicroscopes are the most commonly used instruments for visualizing the ear. Digital otoscopy (DO) could be used to improve diagnostics in primary health care by utilizing image enlargement. The aim of the study was to explore the possibilities of DO in remote consultations.

Materials and Methods

Based on real-life referrals, 45 otologic outpatients were recruited. DO was performed followed by an attending otologist's appointment, serving as the gold standard. Twenty-four patient cases were analyzed on a digital platform as remote consultation cases containing the given referral information supplemented with DO videos (DOVs). A total of 71 evaluations were performed by five otologists. The quality of the DOVs, their suitability for remote consultations, the accuracy of diagnoses and the usefulness of remote consultations were determined.

Results

The average DOV quality was judged to be 7.4 ± 0.3 (mean ± standard error of the mean; scale of 1-10). The diagnosis was correct in 79% of the cases. In 59% of the patients, the otologists considered that remote consultation could have replaced an in-person visit.

Conclusions

In our simulated remote consultation setup, DOV quality was sufficient for diagnostic purposes, DO improved diagnostics and treatment planning in most cases and could be used to reduce the need for in-person visits. DO-aided remote consultation may improve diagnostics and access to care.Level of evidence: 3.

A teleradiology network for the improvement of healthcare and patient management in the developing countries of the African continent

INTRODUCTION

Africa is the second-largest continent on Earth in terms of both size and population. However, inaccessibility and shortfall of trained radiologists impede the delivery of adequate healthcare to such a large population. Teleradiology holds considerable potential in improving patient outcomes and healthcare delivery in African nations by furnishing timely interpretation of radiological examinations, particularly in those areas where there is a particular scarcity of radiologists. The aim of the present study was to assess the impact of teleradiology in the improvement of healthcare and patient management in the developing countries of the African continent.

METHODS

In this retrospective study, from January 2017 and December 2022, the scans of a cohort of patients from eight African countries were uploaded to the teleradiology cloud server and interpreted by board certified radiologists empanelled by a teleradiology service provider.

RESULTS

The telehealth model proposed in the study was seen to provide timely and quality reporting of 58,223 scans of 39,513 patients with a mean turn-around-time (TAT) of 2.46 h 95 % CI (2.44-2.48).

DISCUSSION

A dedicated teleradiology model designed in this study allowed the interpretation and analysis of the scans of the cohort of patients from hospitals in African countries by teleradiologists via high quality DICOM-image transfer over a cloud-based platform. The outcomes of our investigation reflect that teleradiology provides an effective solution for early diagnosis/interpretation of examinations performed in Africa. Further, the currently proposed teleradiology model may be used for other developing countries across the world to improve quality of care.

Digital vs. physical ear-nose-and-throat specialist assessment screening for complicated hearing loss and serious ear disorders in hearing-impaired adults prior to hearing aid treatment: a randomized controlled trial

Introduction

This study introduces a digital assessment tool for asynchronous and remote ear-nose-and-throat (ENT) specialist assessment screening for complicated hearing loss and serious ear disorders in hearing-impaired adults prior to hearing aid (HA) treatment. The +60 population will nearly double from 12% to 22% between 2015 and 2050 increasing the incidence of age-induced hearing impairment and the need for hearing rehabilitation. If un-diagnosed, age-related hearing loss negatively affects quality of life by accelerating social distancing and early retirement as well as increasing risk of anxiety, depression, and dementia. Therefore, innovative measures are essential to provide timely diagnostics and treatment.

Methods

A total of 751 hearing-impaired adults without previous HA usage or experience were randomly assigned to digital or physical ENT specialist assessment screening prior to HA treatment initiation in 20 public and private hearing rehabilitation and ENT specialist clinics in the North Denmark Region. A total of 501 test group participants were assigned to digital assessment screening and 250 control group participants to physical assessment screening prior to HA treatment.

Results

In all, 658 (88%) participants completed the trial and were eligible for analysis. Digital screening sensitivity (0.85, 95% confidence interval (CI) 0.71-0.94) was significantly higher than physical screening sensitivity (0.2, 95% CI: 0.03-0.56). Screening specificity was high for both assessment methods.

Discussion

In a setting where hearing-impaired adults were assessed for HA treatment, digital ENT specialist assessment screening did not compromise patient safety or increase the risk of misdiagnosis in patients with complicated hearing loss and/or serious ear disorders when compared to physical ENT specialist assessment screening.

Clinical Trial registration

https://clinicaltrials.gov/ct2/show/NCT05154539, identifier: NCT05154539.

Accuracy and reliability of tele-ultrasonography in detecting gastrointestinal obstruction in dogs and cats

OBJECTIVES

To assess the accuracy and interobserver agreement of tele-ultrasonography for the diagnosis of gastrointestinal obstruction in small animals by radiologists with different levels of experience.

MATERIALS AND METHODS

A retrospective cross-sectional study including dogs and cats admitted with gastrointestinal signs, between 2017 and 2019, that had abdominal ultrasonographic (US) examination performed and images saved for review. Patients were classified into two categories based on final diagnosis: animals with or without complete or partial gastrointestinal obstruction. Observers with four experience levels interpreted the archived ultrasound examinations, simulating a tele-ultrasonography consultation. Analyses of accuracy, sensitivity, specificity, positive and negative predictive values were obtained for each observer for detection of gastrointestinal obstruction. Agreement between observers for the gastrointestinal obstruction diagnosis was assessed using Fleiss's Kappa statistics.

RESULTS

Ninety patients with gastrointestinal signs were included. Of these, 23 of 90 had partial or complete gastrointestinal obstruction. Interpretation of the images by observers via tele-ultrasonography showed intervals of accuracy, sensitivity, specificity, positive and negative predictive values, respectively, of 78.9% to 87.8%, 73.9% to 100%, 77.6% to 89.6%, 55.9% to 70.8% and 90.9% to 100% for diagnosis of gastrointestinal obstruction. Agreement for the gastrointestinal obstruction diagnosis across all reviewers was moderate (Kappa 0.6).

CLINICAL SIGNIFICANCE

Tele-ultrasonography had good accuracy for detection of gastrointestinal obstruction, however had a rather low positive predictive value and only moderate interobserver agreement. Therefore, this technique should be used with caution in this clinical context, given the potential surgical decision at hand.

Digital transformation of career landscapes in radiology: personal and professional implications

Millennial radiology is marked by technical disruptions. Advances in internet, digital communications and computing technology, paved way for digitalized workflow orchestration of busy radiology departments. The COVID pandemic brought teleradiology to the forefront, highlighting its importance in maintaining continuity of radiological services, making it an integral component of the radiology practice. Increasing computing power and integrated multimodal data are driving incorporation of artificial intelligence at various stages of the radiology image and reporting cycle. These have and will continue to transform the career landscape in radiology, with more options for radiologists with varied interests and career goals. The ability to work from anywhere and anytime needs to be balanced with other aspects of life. Robust communication, internal and external collaboration, self-discipline, and self-motivation are key to achieving the desired balance while practicing radiology the unconventional way.

Optimizing Primary Healthcare in Hong Kong: Strategies for the Successful Integration of Radiology Services

The primary healthcare system in Hong Kong plays a crucial role in addressing the healthcare needs of its population. However, the integration of radiology services into primary care settings has not been fully realized, and there is significant potential for improvement. Incorporating radiology services into primary healthcare can enhance patient care, promote cost-effectiveness, and increase the overall efficiency of the healthcare system by enabling earlier diagnosis and intervention for various health conditions. To successfully integrate radiology services, key strategies include the establishment of public-private partnerships, the adoption of teleradiology and telemedicine services, the development of comprehensive regulatory and policy frameworks, and the exploration of innovative financial models and incentives. By embracing these strategies, Hong Kong can optimize its primary healthcare system and ensure more equitable, effective care for its population.

Teleradiology: good practice guide

Teleradiology is the electronic transmission of radiological images from one location to another with the main purpose of interpreting or consulting a diagnosis and must be subject to codes of conduct agreed upon by professional societies. The content of fourteen teleradiology best practice guidelines is analyzed. Their guiding principles are: the best interest and benefit of the patient, quality and safety standards homologous to the local radiology service, and use as a complement and support of the same. As legal obligations: guaranteeing rights by applying the principle of the patient's country of origin, establishing requirements in international teleradiology and civil liability insurance. Regarding the radiological process: integration with the local service process, guaranteeing the quality of images and reports, access to previous studies and reports and complying with the principles of radioprotection. Regarding professional requirements: compliance with the required registrations, licenses and qualifications, training and qualification of the radiologist and technician, prevention of fraudulent practices, respect for labor standards and remuneration of the radiologist. Subcontracting must be justified, managing the risk of commoditization. Compliance with the system's technical standards.

An Overview of Telehealth in the Management of Cardiovascular Disease: A Scientific Statement From the American Heart Association

Telehealth enables the remote delivery of health care through telecommunication technologies and has substantially affected the evolving medical landscape. The COVID-19 pandemic accelerated the utilization of telehealth as health care professionals were forced to limit face-to-face in-person visits. It has been shown that information delivery, diagnosis, disease monitoring, and follow-up care can be conducted remotely, resulting in considerable changes specific to cardiovascular disease management. Despite increasing telehealth utilization, several factors such as technological infrastructure, reimbursement, and limited patient digital literacy can hinder the adoption of remote care. This scientific statement reviews definitions pertinent to telehealth discussions, summarizes the effect of telehealth utilization on cardiovascular and peripheral vascular disease care, and identifies obstacles to the adoption of telehealth that need to be addressed to improve health care accessibility and equity.

Effectiveness of Telemedicine and Teledentistry after the COVID-19 Pandemic

Telemedicine has become increasingly important worldwide over the last two decades. As a new field, it became known especially during the COVID-19 pandemic; this review presents fields of activity with special attention to opportunities and risks. Numerous areas of application offer the possibility for broad use in the medical and dental care landscape in diagnostics, therapy, rehabilitation, and decision advice across a spatial distance. Technical and semantic standards are required, and profiles and guidelines are increasingly defined and organized. Medical/dental consultations have been established in various regions around the world as a response to pandemic challenges and have made video and online emergency consultations possible. Telemedicine applications are already regularly used in medical/dental emergencies, regardless of the pandemic situation, both for transport by train and by plane, from which patients benefit. However, legal hurdles are often still unresolved, but infrastructure challenges both for provider, user hard- and software also complicate deployment. Problems are particularly prevalent in the absence of necessary internet coverage or among socially disadvantaged and vulnerable groups who cannot afford expensive equipment or do not know how to use the technology. Broad access must be enabled, and hardware and software interfaces and updates must be regularly checked and updated. Telemedicine might also improve access to and delivery of oral and general health care support both for rural and urban areas with low costs. Even though dentistry and many medical specialties are still performed clinically by means of practical/manual examination, there are areas of diagnostics where telemedicine applications can provide good support. Therefore, as conclusions, access, and delivery of telemedicine applications in dentistry and medicine should be expanded and improved to provide access to all population groups.

Emergency Teleradiology-Past, Present, and, Is There a Future?

Emergency radiology has evolved into a distinct radiology subspecialty requiring a specialized skillset to make a timely and accurate diagnosis of acutely and critically ill or traumatized patients. The need for emergency and odd hour radiology coverage fuelled the growth of internal and external teleradiology and the "nighthawk" services to meet the increasing demands from all stakeholders and support the changing trends in emergency medicine and trauma surgery inclined toward increased reliance on imaging. However, the basic issues of increased imaging workload, radiologist demand-supply mismatch, complex imaging protocols are only partially addressed by teleradiology with the promise of workload balancing by operations to scale. Incorporation of artificially intelligent tools helps scale manifold by the promise of streamlining the workflow, improved detection and quantification as well as prediction. The future of emergency teleradiologists and teleradiology groups is entwined with their ability to incorporate such tools at scale and adapt to newer workflows and different roles. This agility to adopt and adapt would determine their future.

Teleradiology in India during the COVID-19 pandemic: Merits, pitfalls and a Future Perspective

The field of teleradiology has been of interest for almost 55 years and its potential prospects for health care have been constantly assessed and investigated. In view of the global preventive measures, such as social distancing and hand hygiene, the ongoing COVID-19 pandemic has further accentuated the necessity of telemedicine and teleradiology. In a country as densely populated as India wherein radiologists are often fragmented, teleradiology can prove to be a lifesaving technology and aid dampen the repercussions stemming from the highly skewed doctor to patient ratio. Although innovative, the effective adoption of teleradiology faces several obstacles in India such as inadequate technological infrastructure, a lack of knowledge among most medical practitioners, urban-rural disparities, and a lack of financing. Similar challenges continue to also be faced by several other developing countries across the globe. This article therefore aims to elaborate on the most important facets of implementation of teleradiology observed in the Indian context to help provide salient pointers to the readership of relevant jurisdictions who may be embracing comparable teleradiology challenges. Despite the hurdles, the future of teleradiology seems promising. The respective governments, policymakers and all relevant stakeholders must continue to take decisive action to ensure that this potential is fully exploited by allocation of necessary funds, strengthening of Information Technology and its related units, involvement of human resources with adequate technical and administrative expertise as well as take continued action to better existing telemedicine and teleradiology services.

The Artificial Intelligence in Digital Radiology: Part 2: Towards an Investigation of acceptance and consensus on the Insiders

Background. The study deals with the introduction of the artificial intelligence in digital radiology. There is a growing interest in this area of scientific research in acceptance and consensus studies involving both insiders and the public, based on surveys focused mainly on single professionals. Purpose. The goal of the study is to perform a contemporary investigation on the acceptance and the consensus of the three key professional figures approaching in this field of application: (1) Medical specialists in image diagnostics: the medical specialists (MS)s; (2) experts in physical imaging processes: the medical physicists (MP)s; (3) AI designers: specialists of applied sciences (SAS)s. Methods. Participants (MSs = 92: 48 males/44 females, averaged age 37.9; MPs = 91: 43 males/48 females, averaged age 36.1; SAS = 90: 47 males/43 females, averaged age 37.3) were properly recruited based on specific training. An electronic survey was designed and submitted to the participants with a wide range questions starting from the training and background up to the different applications of the AI and the environment of application. Results. The results show that generally, the three professionals show (a) a high degree of encouraging agreement on the introduction of AI both in imaging and in non-imaging applications using both standalone applications and/or mHealth/eHealth, and (b) a different consent on AI use depending on the training background. Conclusions. The study highlights the usefulness of focusing on both the three key professionals and the usefulness of the investigation schemes facing a wide range of issues. The study also suggests the importance of different methods of administration to improve the adhesion and the need to continue these investigations both with federated and specific initiatives.

The concept of the invisible radiologist in the era of artificial intelligence

The radiologists were traditionally working in the background. What upgraded them as physicians during the second half of the past century was their clinical training and function precipitated by the evolution of Interventional Radiology and Medical Imaging, especially with ultrasonography. These allowed them to participate in patient's diagnosis and treatment by direct contact as well asvia multidisciplinary medical consultations. The wide application of teleradiology and PACS pushed radiologists back again which is no longer acceptable, especially in view of the amazing applications of artificial intelligence (AI) in Radiology. It is our belief that clinical radiologists have to be able to control the penetration of AI in Radiology, securing their work for the benefit of both clinicians and patients.

Obstacles and Solutions Driving the Development of a National Teleradiology Network

Background: Teleradiology has the potential to link medical experts and specialties despite geographical separation. In a project report about hospital-based teleradiology, the significance of technical and human factors during the implementation and growth of a teleradiology network are explored. Evaluation: The article identifies major obstacles during the implementation and growth of the teleradiology network of the Berlin Trauma Hospital (BG Unfallkrankenhaus Berlin) between 2004 and 2020 in semi-structured interviews with senior staff members. Quantitative analysis of examination numbers, patient numbers, and profits relates the efforts of the staff members to the monetary benefits and success of the network. Identification of qualitative and quantitative factors for success: Soft and hard facilitators and solutions driving the development of the national teleradiology network are identified. Obstacles were often solved by technical innovations, but the time span between required personal efforts, endurance, and flexibility of local and external team members. The article describes innovations driven by teleradiology and hints at the impact of teleradiology on modern medical care by relating the expansion of the teleradiology network to patient transfers and profits. Conclusion: In addition to technical improvements, interpersonal collaborations were key to the success of the teleradiology network of the Berlin Trauma Hospital and remained a unique feature and selling point of this teleradiology network.

Clinical Outcomes of Asynchronous Versus Synchronous Telepsychiatry in Primary Care: Randomized Controlled Trial

BACKGROUND

Asynchronous telepsychiatry (ATP; delayed-time) consultations are a novel form of psychiatric consultation in primary care settings. Longitudinal studies comparing clinical outcomes for ATP with synchronous telepsychiatry (STP) are lacking.

OBJECTIVE

This study aims to determine the effectiveness of ATP in improving clinical outcomes in English- and Spanish-speaking primary care patients compared with STP, the telepsychiatry usual care method.

METHODS

Overall, 36 primary care physicians from 3 primary care clinics referred a heterogeneous sample of 401 treatment-seeking adult patients with nonurgent psychiatric disorders. A total of 184 (94 ATP and 90 STP) English- and Spanish-speaking participants (36/184, 19.6% Hispanic) were enrolled and randomized, and 160 (80 ATP and 80 STP) of them completed baseline evaluations. Patients were treated by their primary care physicians using a collaborative care model in consultation with the University of California Davis Health telepsychiatrists, who consulted with patients every 6 months for up to 2 years using ATP or STP. Primary outcomes (the clinician-rated Clinical Global Impressions [CGI] scale and the Global Assessment of Functioning [GAF]) and secondary outcomes (patients' self-reported physical and mental health and depression) outcomes were assessed every 6 months.

RESULTS

For clinician-rated primary outcomes, ATP did not promote greater improvement than STP at 6-month follow-up (ATP vs STP, adjusted difference in follow-up at 6 months vs baseline differences for CGI: 0.2, 95% CI -0.2 to 0.6; P=.28; and GAF: -0.6, 95% CI -3.1 to 1.9; P=.66) or 12-month follow-up (ATP vs STP, adjusted difference in follow-up at 12 months vs baseline differences for CGI: 0.4, 95% CI -0.04 to 0.8; P=.07; and GAF: -0.5, 95% CI -3.3 to 2.2; P=.70), but patients in both arms had statistically and clinically significant improvements in both outcomes. There were no significant differences in improvement from baseline between ATP and STP on any patient self-reported ratings at any follow-up (all P values were between .17 and .96). Dropout rates were higher than predicted but similar between the 2 arms. Of those with baseline visits, 46.8% (75/160) did not have a follow-up at 1 year, and 72.7% (107/147) did not have a follow-up at 2 years. No serious adverse events were associated with the intervention.

CONCLUSIONS

This is the first longitudinal study to demonstrate that ATP can improve clinical outcomes in English- and Spanish-speaking primary care patients. Although we did not find evidence that ATP is superior to STP in improving clinical outcomes, it is potentially a key part of stepped mental health interventions available in primary care. ATP presents a possible solution to the workforce shortage of psychiatrists and a strategy for improving existing systems of care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.

COVID-19 imaging: Diagnostic approaches, challenges, and evolving advances

The role of radiology and the radiologist have evolved throughout the coronavirus disease-2019 (COVID-19) pandemic. Early on, chest computed tomography was used for screening and diagnosis of COVID-19; however, it is now indicated for high-risk patients, those with severe disease, or in areas where polymerase chain reaction testing is sparsely available. Chest radiography is now utilized mainly for monitoring disease progression in hospitalized patients showing signs of worsening clinical status. Additionally, many challenges at the operational level have been overcome within the field of radiology throughout the COVID-19 pandemic. The use of teleradiology and virtual care clinics greatly enhanced our ability to socially distance and both are likely to remain important mediums for diagnostic imaging delivery and patient care. Opportunities to better utilize of imaging for detection of extrapulmonary manifestations and complications of COVID-19 disease will continue to arise as a more detailed understanding of the pathophysiology of the virus continues to be uncovered and identification of predisposing risk factors for complication development continue to be better understood. Furthermore, unidentified advancements in areas such as standardized imaging reporting, point-of-care ultrasound, and artificial intelligence offer exciting discovery pathways that will inevitably lead to improved care for patients with COVID-19.

The Accuracy of On-Call CT Reporting in Teleradiology Networks in Comparison to In-House Reporting

(1) Background: We aimed to compare the accuracy of after-hours CT reports created in a traditional in-house setting versus a teleradiology setting by assessing the discrepancy rates between preliminary and final reports. (2) Methods: We conducted a prospective study to determine the number and severity of discrepancies between preliminary and final reports for 7761 consecutive after-hours CT scans collected over a 21-month period. CT exams were performed during on-call hours and were proofread by an attending the next day. Discrepancies between preliminary and gold-standard reports were evaluated by two senior attending radiologists, and differences in rates were assessed for statistical significance. (3) Results: A total of 7209 reports were included in the analysis. Discrepancies occurred in 1215/7209 cases (17%). Among these, 433/7209 reports (6%) showed clinically important differences between the preliminary and final reports. A total of 335/5509 of them were in-house reports (6.1%), and 98/1700 were teleradiology reports (5.8%). The relative frequencies of report changes were not significantly higher in teleradiology. (4) Conclusions: The accuracy of teleradiology reports was not inferior to that of in-house reports, with very similar clinically important differences rates found in both reporting situations.

Evaluation of Free, Open-source, Web-based DICOM Viewers for the Indian National Telemedicine Service (eSanjeevani)

The Digital Image and Communications in Medicine (DICOM) viewer is a very useful component in telemedicine applications. Owing to increased demand, adoption, and prospects of browser-based software in the recent past, web-based DICOM viewers have gained significant ground. There are myriad web-based DICOM viewers which are open source and are available free of cost as stand-alone applications. These freely available tools have rich functionality like the commercial ones. To find an optimal DICOM viewer for integration with a web-based telemedicine solution is quite a challenge, and no research has gone into assessing these freely available DICOM viewers. This research assessed a range of web-based, open-source, and freely available DICOM viewers from the perspective of their integration with the Indian National Telemedicine Solution (eSanjeevani). To introduce teleradiology module in eSanjeevani, a study is carried out to enable viewing of radiological images through DICOM viewer. eSanjeevani is being prepared for a national roll-out at 155,000 health and wellness centers across rural India by the Ministry of Health and Family Welfare (Government of India) under the Ayushman Bharat Scheme (the world's largest health insurance scheme). In total, 13 free, open-source, and web-based DICOM viewers were identified for evaluation; however, only six were shortlisted as assessed. This study can serve as a one-stop source for researchers looking for a suitable DICOM viewer for their healthcare IT applications.

Emerging Challenges and Opportunities in the Evolution of Teleradiology

OBJECTIVE. In recent decades, teleradiology has expanded considerably, and many radiology practices now engage in intraorganizational or extraorganizational teleradiology. In this era of patient primacy, optimizing patient care and care delivery is paramount. This article provides an update on recent changes, current challenges, and future opportunities centered around the ability of teleradiology to improve temporal and geographic imaging access. We review licensing and regulations and discuss teleradiology in providing services to rural areas and assisting with disaster response, including the response to the coronavirus disease (COVID-19) pandemic. CONCLUSION. Teleradiology can help increase imaging efficiency and mitigate both geographic and temporal discrepancies in imaging care. Technologic limitations and regulatory hurdles hinder the optimal practice of teleradiology, and future attention to these issues may help ensure broader patient access to high-quality imaging across the United States.

Migrating to the Modern PACS: Challenges and Opportunities

With progressive advancements in picture archiving and communication system (PACS) technology, radiology practices frequently look toward system upgrades and replacements to further improve efficiency and capabilities. The transition between PACS has the potential to derail the operations of a radiology department. Careful planning and attention to detail from radiology informatics leaders are imperative to ensure a smooth transition. This article is a review of the architecture of a modern PACS, highlighting areas of recent innovation. Key considerations for planning a PACS migration and important issues to consider in data migration, change management, and business continuity are discussed. Beyond the technical aspects of a PACS migration, the human factors to consider when managing the cultural change that accompanies a new informatics tool and the keys to success when managing technical failures are explored. Online supplemental material is available for this article. ^©RSNA, 2018.

The Current State of Teleradiology Across the United States: A National Survey of Radiologists' Habits, Attitudes, and Perceptions on Teleradiology Practice

PURPOSE

To explore the current state of teleradiology practice, defined as the interpretation of imaging examinations at a different facility from where the examination was performed.

METHODS

A national survey addressing radiologists' habits, attitudes, and perceptions regarding teleradiology was distributed by e-mail to a random sample of ACR members in early 2019.

RESULTS

Among 731 of 936 respondents who indicated a non-teleradiologist primary work setting, 85.6% reported performing teleradiology within the past 10 years and 25.4% reported that teleradiology represents a majority of their annual imaging volumes; 84.4% performed teleradiology for internal examinations and 45.7% for external examinations; 46.2% performed teleradiology for rural areas and 37.2% for critical access hospitals; 91.3% performed teleradiology during weekday normal business hours and 44.5% to 79.6% over evening, overnight, and weekend hours. In all, 76.9% to 86.2% perceived value from teleradiology for geographic, after-hours, and multispecialty coverage, as well as reduced interpretation turnaround times. The most common challenges for teleradiology were electronic health record access (62.8%), quality assurance (53.8%), and technologist proximity (48.4%). The strategy most commonly considered useful for improving teleradiology was technical interpretation standards (33.3%). Radiologists in smaller practices were less likely to perform teleradiology or performed teleradiology for lower fractions of work, were less likely to experience coverage advantages of teleradiology, and reported larger implementation challenges, particularly relating to electronic health records and prior examination access.

CONCLUSION

Despite historic concerns, teleradiology is widespread throughout modern radiology practice, helping practices achieve geographic, after-hours, and multispecialty coverage; reducing turnaround times; and expanding underserved access. Nonetheless, quality assurance of offsite examinations remains necessary. IT integration solutions could help smaller practices achieve teleradiology's benefits.

Teledermatology: A Review and Update

Telemedicine is slowly transforming the way in which healthcare is delivered and has the potential to improve access to subspecialty expertise, reduce healthcare costs, and improve the overall quality of care. While many subspecialty fields within medicine today have either experimented with or begun to implement telemedicine platforms to enable remote consultation and care, dermatology is particularly suited for this care system as skin disorders are uniquely visible to the human eye. Through teledermatology, diagnostic images of skin disorders with accompanying clinical histories can be remotely reviewed by teledermatologists by any number of modalities, such as photographic clinical images or live video teleconferencing. Diagnoses and treatment recommendations can then be rendered and implemented remotely. The evidence to date supports both its diagnostic and treatment accuracy and its cost effectiveness. Administrative, regulatory, privacy, and reimbursement policies surrounding this dynamic field continue to evolve. In this review, we examine the history, evidence, and administrative landscape surrounding teledermatology and discuss current practice guidelines and ongoing controversies.

The Empirical Foundations of Teleradiology and Related Applications: A Review of the Evidence

INTRODUCTION

Radiology was founded on a technological discovery by Wilhelm Roentgen in 1895. Teleradiology also had its roots in technology dating back to 1947 with the successful transmission of radiographic images through telephone lines. Diagnostic radiology has become the eye of medicine in terms of diagnosing and treating injury and disease. This article documents the empirical foundations of teleradiology.

METHODS

A selective review of the credible literature during the past decade (2005-2015) was conducted, using robust research design and adequate sample size as criteria for inclusion.

FINDINGS

The evidence regarding feasibility of teleradiology and related information technology applications has been well documented for several decades. The majority of studies focused on intermediate outcomes, as indicated by comparability between teleradiology and conventional radiology. A consistent trend of concordance between the two modalities was observed in terms of diagnostic accuracy and reliability. Additional benefits include reductions in patient transfer, rehospitalization, and length of stay.

Radiochemistry, PET Imaging, and the Internet of Chemical Things

The Internet of Chemical Things (IoCT), a growing network of computers, mobile devices, online resources, software suites, laboratory equipment, synthesis apparatus, analytical devices, and a host of other machines, all interconnected to users, manufacturers, and others through the infrastructure of the Internet, is changing how we do chemistry. While in its infancy across many chemistry laboratories and departments, it became apparent when considering our own work synthesizing radiopharmaceuticals for positron emission tomography (PET) that a more mature incarnation of the IoCT already exists. How does the IoCT impact our lives today, and what does it hold for the smart (radio)chemical laboratories of the future?

Achieving regionalization through rural interhospital transfer

Regionalization of emergency medical care aims to provide consistent and efficient high-quality care leading to optimal clinical outcomes by matching patient needs with appropriate resources at a network of hospitals. Regionalized care has been shown to improve outcomes in trauma, myocardial infarction, stroke, cardiac arrest, and acute respiratory distress syndrome. In rural areas, effective regionalization often requires interhospital transfer. The decision to transfer is complex and includes such factors as capabilities of the presenting hospital; capacity at the receiving hospital; and financial, geographic, and patient-preference considerations. Although transfer to a comprehensive center has proven benefits for some conditions, the transfer process is not without risk. These risks include clinical deterioration, limited resource availability during transport, vehicular crashes, time delays for time-sensitive care, poor communication between providers, and neglect of patient preferences. This article reviews the transfer decision, financial implications, risks, and considerations for patients undergoing rural interhospital transfer. We identify several strategies that should be considered for development of the regionalized emergency health care system of the future and identify areas where further research is necessary.

Towards social radiology as an information infrastructure: reconciling the local with the global

The current widespread use of medical images and imaging procedures in clinical practice and patient diagnosis has brought about an increase in the demand for sharing medical imaging studies among health professionals in an easy and effective manner. This article reveals the existence of a polarization between the local and global demands for radiology practice. While there are no major barriers for sharing such studies, when access is made from a (local) picture archive and communication system (PACS) within the domain of a healthcare organization, there are a number of impediments for sharing studies among health professionals on a global scale. Social radiology as an information infrastructure involves the notion of a shared infrastructure as a public good, affording a social space where people, organizations and technical components may spontaneously form associations in order to share clinical information linked to patient care and radiology practice. This article shows however, that such polarization establishes a tension between local and global demands, which hinders the emergence of social radiology as an information infrastructure. Based on an analysis of the social space for radiology practice, the present article has observed that this tension persists due to the inertia of a locally installed base in radiology departments, for which common teleradiology models are not truly capable of reorganizing as a global social space for radiology practice. Reconciling the local with the global signifies integrating PACS and teleradiology into an evolving, secure, heterogeneous, shared, open information infrastructure where the conceptual boundaries between (local) PACS and (global) teleradiology are transparent, signaling the emergence of social radiology as an information infrastructure.

A low-cost tele-imaging platform for developing countries

PURPOSE

To design a "low-cost" tele-imaging method allowing real-time tele-ultrasound expertise, delayed tele-ultrasound diagnosis, and tele-radiology between remote peripherals hospitals and clinics (patient centers) and university hospital centers (expert center).

MATERIALS AND METHODS

A system of communication via internet (IP camera and remote access software) enabling transfer of ultrasound videos and images between two centers allows a real-time tele-radiology expertise in the presence of a junior sonographer or radiologist at the patient center. In the absence of a sonographer or radiologist at the patient center, a 3D reconstruction program allows a delayed tele-ultrasound diagnosis with images acquired by a lay operator (e.g., midwife, nurse, technician). The system was tested both with high and low bandwidth. The system can further accommodate non-ultrasound tele-radiology (conventional radiography, mammography, and computer tomography for example). The system was tested on 50 patients between CHR Tsevie in Togo (40 km from Lomé-Togo and 4500 km from Tours-France) and CHU Campus at Lomé and CHU Trousseau in Tours.

RESULTS

A real-time tele-expertise was successfully performed with a delay of approximately 1.5 s with an internet bandwidth of around 1 Mbps (IP Camera) and 512 kbps (remote access software). A delayed tele-ultrasound diagnosis was also performed with satisfactory results. The transmission of radiological images from the patient center to the expert center was of adequate quality. Delayed tele-ultrasound and tele-radiology was possible even in the presence of a low-bandwidth internet connection.

CONCLUSION

This tele-imaging method, requiring nothing by readily available and inexpensive technology and equipment, offers a major opportunity for telemedicine in developing countries.

The past, present, and future of telemedicine for Parkinson's disease

Travel distance, growing disability, and uneven distribution of doctors limit access to care for most Parkinson's disease (PD) patients worldwide. Telemedicine, the use of telecommunications technology to deliver care at a distance, can help overcome these barriers. In this report, we describe the past, present, and likely future applications of telemedicine to PD. Historically, telemedicine has relied on expensive equipment to connect single patients to a specialist in pilot programs in wealthy nations. As the cost of video conferencing has plummeted, these efforts have expanded in scale and scope, now reaching larger parts of the world and extending the focus from care to training of remote providers. Policy, especially limited reimbursement, currently hinders the growth and adoption of these new care models. As these policies change and technology advances and spreads, the following will likely develop: integrated care networks that connect patients to a wide range of providers; education programs that support patients and health care providers; and new research applications that include remote monitoring and remote visits. Together, these developments will enable more individuals with PD to connect to care, increase access to expertise for patients and providers, and allow more-extensive, less-expensive participation in research.

University-Based Teleradiology in the United States

This article reviews the University of Arizona's more than 15 years of experience with teleradiology and provides an overview of university-based teleradiology practice in the United States (U.S.). In the U.S., teleradiology is a major economic enterprise with many private for-profit companies offering national teleradiology services (i.e., professional interpretation of radiologic studies of all types by American Board of Radiology certified radiologists). The initial thrust for teleradiology was for after-hours coverage of radiologic studies, but teleradiology has expanded its venue to include routine full-time or partial coverage for small hospitals, clinics, specialty medical practices, and urgent care centers. It also provides subspecialty radiologic coverage not available at smaller medical centers and clinics. Many U.S. university-based academic departments of radiology provide teleradiology services usually as an additional for-profit business to supplement departmental income. Since academic-based teleradiology providers have to compete in a very demanding marketplace, their success is not guaranteed. They must provide timely, high-quality professional services for a competitive price. Academic practices have the advantage of house officers and fellows who can help with the coverage, and they have excellent subspecialty expertise. The marketplace is constantly shifting, and university-based teleradiology practices have to be nimble and adjust to ever-changing situations.

Hyperacute management of ischemic stroke

Stroke is a devastating disease and currently the fourth leading cause of death in this country. Acute ischemic stroke is an emergency and requires effective triage, diagnosis, and critical management. The hyperacute management of ischemic stroke begins in the field, with recognition of stroke symptoms by emergency medical systems (EMS) personnel. The EMS is an important component to an effective stroke system of care, which also includes primary stroke centers, routing protocols for acute ischemic stroke, and telemedicine. Following the arrival of a potential stroke patient to the emergency room setting, patients should be stabilized and undergo assessment for potential intravenous alteplase (IV tPA) treatment. Assessments include diagnostic tests, neuroimaging, and standardized stroke evaluations. After these assessments have been performed, IV tPA, the only medication for acute stroke approved by the U.S. Food and Drug Administration, can be considered using a variety of inclusion and exclusion criteria. Previously time restrictions limited the usage of IV tPA to 3 hours, but this time window has now been extended for eligible candidates to 4.5 hours. The administration of IV tPA has specific requirements for monitoring and should be standardized via protocol across hospitals.

Facilitating Stroke Management using Modern Information Technology

BACKGROUND AND PURPOSE

Information technology and mobile devices may be beneficial and useful in many aspects of stroke management, including recognition of stroke, transport and triage of patients, emergent stroke evaluation at the hospital, and rehabilitation. In this review, we address the contributions of information technology and mobile health to stroke management.

SUMMARY OF ISSUES

Rapid detection and triage are essential for effective thrombolytic treatment. Awareness of stroke warning signs and responses to stroke could be enhanced by using mobile applications. Furthermore, prehospital assessment and notification could be streamlined for use in telemedicine and teleradiology. A mobile telemedicine system for assessing the National Institutes of Health Stroke Scale scores has shown higher correlation and fast assessment comparing with face-to-face method. Because the benefits of thrombolytic treatment are time-dependent, treatment should be initiated as quickly as possible. In-hospital communication between multidisciplinary team members can be enhanced using information technology. A computerized in-hospital alert system using computerized physician-order entry was shown to be effective in reducing the time intervals from hospital arrival to medical evaluations and thrombolytic treatment. Mobile devices can also be used as supplementary tools for neurologic examination and clinical decision-making. In post-stroke rehabilitation, virtual reality and telerehabilitation are helpful. Mobile applications might be useful for public awareness, lifestyle modification, and education/training of healthcare professionals.

CONCLUSIONS

Information technology and mobile health are useful tools for management of stroke patients from the acute period to rehabilitation. Further improvement of technology will change and enhance stroke prevention and treatment.

Factors in the selection of a teleradiology provider in the United States

Commercial teleradiology is well established in the US. There are many factors to consider when engaging a teleradiology provider. One of the basic questions is what do you expect to gain from it? Do you want a final reading from an attending radiologist (known as a consultant radiologist in many countries) or would you be satisfied with a preliminary reading from a teleradiology provider and a final reading from your own in-house radiologist the following day? Do you simply require after-hours coverage or do you need to supplement the coverage provided by your own internal radiologists during normal working hours? Teleradiology is not without its drawbacks. It can add additional costs, particularly for after-hours coverage. Teleradiology rarely provides in-house coverage for procedures, and the interpreting radiologist may sometimes be difficult to contact for consultation. Choosing a teleradiology vendor requires due diligence. When the contracting entity defines its expectations well and chooses its teleradiology vendor with care, the end result will be satisfactory for all concerned, including the patients.

Teleradiology from the provider's perspective-cost analysis for a mid-size university hospital

OBJECTIVES

Real costs of teleradiology services have not been systematically calculated. Pricing policies are not evidence-based. This study aims to prove the feasibility of performing an original cost analysis for teleradiology services and show break-even points to perform cost-effective practice.

METHODS

Based on the teleradiology services provided by the Greifswald University Hospital in northeastern Germany, a detailed process analysis and an activity-based costing model revealed costs per service unit according to eight examination categories. The Monte Carlo method was used to simulate the cost amplitude and identify pricing thresholds.

RESULTS

Twenty-two sub-processes and four staff categories were identified. The average working time for one unit was 55 (x-ray) to 72 min (whole-body CT). Personnel costs were dominant (up to 68 %), representing lower limit costs. The Monte Carlo method showed the cost distribution per category according to the deficiency risk. Avoiding deficient pricing by a likelihood of 90 % increased the cost of a cranial CT almost twofold as compared with the lower limit cost.

CONCLUSIONS

Original cost analysis is possible when providing teleradiology services with complex statutory requirements in place. Methodology and results provide useful data to help enhance efficiency in hospital management as well as implement realistic reimbursement fees.

KEY POINTS

• Analysis of original costs of teleradiology is possible for a providing hospital • Results discriminate pricing thresholds and lower limit costs to perform cost-effective practice • The study methods represent a managing tool to enhance efficiency in providing facilities • The data are useful to help represent telemedicine services in regular medical fee schedules.

Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates.

METHODS

Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm.

RESULTS

The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation.

CONCLUSIONS

Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.

Remote sonographic interpretation: comparison of standardized video clips to still images

OBJECTIVE

The aim of our study was to evaluate the role of standardized video clips compared with still images in the diagnostic accuracy of remote sonographic interpretation.

METHODS

We compared the remote interpretation of sonographic examinations acquired with a standardized video clip approach to examinations performed with still images alone in 60 patients with various hepatic and extrahepatic pathologies.

RESULTS

The use of video clips improved the diagnostic accuracy of sonographic studies interpreted remotely compared with the use of still images (p < 0.0001). The sensitivity, specificity, and positive and negative predictive values increased from 47.3% to 68.3%, 81.8% to 87.8%, 71.5% to 81%, and 63.8% to 74.5%, respectively.

CONCLUSIONS

Standardized video clips are easy to obtain, less operator-dependent than still images, and can be transferred to remote sites without loss of important data. We recommend this method in remote interpretation (teleradiology and distant consultation) of sonographic examinations.

Teleradiology with uncompressed digital mammograms: clinical assessment

PURPOSE

The purpose of our study was to demonstrate the feasibility of sending uncompressed digital mammograms in a teleradiologic setting without loss of information by comparing image quality, lesion detection, and BI-RADS assessment.

MATERIALS AND METHODS

CDMAM phantoms were sent bidirectionally to two hospitals via the network. For the clinical aspect of the study, 200 patients were selected based on the BI-RAD system: 50% BI-RADS I and II; and 50% BI-RADS IV and V. Two hundred digital mammograms (800 views) were sent to two different institutions via a teleradiology network. Three readers evaluated those 200 mammography studies at institution 1 where the images originated, and in the two other institutions (institutions 2 and 3) where the images were sent. The readers assessed image quality, lesion detection, and BI-RADS classification.

RESULTS

Automatic readout showed that CDMAM image quality was identical before and after transmission. The image quality of the 200 studies (total 600 mammograms) was rated as very good or good in 90-97% before and after transmission. Depending on the institution and the reader, only 2.5-9.5% of all studies were rated as poor. The congruence of the readers with respect to the final BI-RADS assessment ranged from 90% and 91% at institution 1 vs. institution 2, and from 86% to 92% at institution 1 vs. institution 3. The agreement was even higher for conformity of content (BI-RADS I or II and BI-RADS IV or V). Reader agreement in the three different institutions with regard to the detection of masses and calcifications, as well as BI-RADS classification, was very good (κ: 0.775-0.884). Results for interreader agreement were similar.

CONCLUSION

Uncompressed digital mammograms can be transmitted to different institutions with different workstations, without loss of information. The transmission process does not significantly influence image quality, lesion detection, or BI-RADS rating.